System-Based Intervention for Medical Providers to Improve Dental Attendance in Adult Primary Care

There are minimal evidence-based outcomes from clinical trials for medical-dental integration. This formative work and pilot study is a precursor to a larger cluster-randomized clinical trial in adult primary care practices to test an electronic health record (EHR) structured workflow for primary care providers (physicians/nurse practitioners [NPs]) and medical staff (medical assistants [MAs] and nurses) with oral health (OH) screening and referral for Medicaid-enrolled adults ≥55 years.

This study was conducted in 2 practices with providers, medical staff, and older adults. Focus groups preceded the pilot study to gain stakeholder insights prior to the multilevel interventions of systems changes and provider education. The system-level EHR changes for medical staff included ask (OH screening), advise (visit dentist soon/annually), assess (need for referral: eReferral to co-located dentists or structured referral to community dentists), and connect (referral; resources). Provider education (didactic and skills) was based on the Common-Sense Model of Self-Regulation (CSM) to deliver OH facts to older adults at primary care visits. Descriptive analysis was used to report on process outcomes of reach, adoption, and implementation/fidelity.

After stakeholder input, the CSM-based didactic and skills curriculum was developed, and 4 physicians were trained. Changes in the Epic EHR were implemented, and 19 medical staff were trained in this new structured workflow together with physicians. In terms of reach, 83% (N = 80) of older adults were enrolled out of 96 approached (female: 66%; non-Hispanic: 83%; Caucasian: 43%). Workflow adoption was 100% of MAs completing the EHR questions and 89% of providers documenting giving OH facts. About 94% of older adults reported their physician giving them OH facts indicating implementation/fidelity of the intervention. About 60% of older adults reported no dental visits in the past year, and 66% requested eReferrals.

This study presents an innovative systems-based multilevel intervention for medical-dental integration.

The results of this study can be used by practice leadership and clinicians when incorporating oral health into primary care for older adults. Considering adoption and implementation costs, this information could lead to a more complete approach to address oral health with patients.